1 OB/GYN Beyond the Objectives. 2 Pregnancies Most are uncomplicated Complications can arise from:...
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Transcript of 1 OB/GYN Beyond the Objectives. 2 Pregnancies Most are uncomplicated Complications can arise from:...
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OB/GYNOB/GYNBeyond the ObjectivesBeyond the Objectives
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Pregnancies
• Most are uncomplicated• Complications can arise from:
• Eclampsia/Pre-eclampsia
• Diabetes
• Hypotension/Hypertension
• Cardiac disorders
• Abortion
• Trauma
• Placenta abnormalities
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Childbirth
• Involves Labor and Delivery
• Natural process, often only requiring basic assistance
• You have at least two patients!
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Childbirth
• Complications can occur• Breech/limb presentation
• Multiple Births
• Umbilical cord problems
• Disproportion
• Excessive bleeding
• Pulmonary embolism
• Neonate requiring resuscitation
• Preterm labor
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Female Reproductive System
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Anatomy/Physiology
• Placenta• Transfer of gases• Transport of nutrients• Excretion of wastes• Hormone production• Protection
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Anatomy/Physiology
• Umbilical cord• Connects placenta to fetus
• Two arteries
• One vein
• Amniotic Sac• Membrane surrounding fetus
• Fluid originates from feral sources
• 500 - 1000 cc (after 20 weeks)
• Rupture produces watery discharge
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Ectopic Pregnancy
• Pathophysiology
• Outside uterine cavity
• 95% Fallopian tubes
• 1 in every 200 pregnancies
• Most are symptomatic
• Predisposing factors
• Tubal infections
• Previous tubal surgery
• IUD use
• previous ectopic pregnancy
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Ectopic Pregnancy
• History• Missed period • Other signs of early pregnancy• Vaginal bleeding 6 -8 weeks after last period
• Upon rupture, bleeding may be excessive
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Ectopic Pregnancy
• History• Lower abdominal pain
• May be: • Sharp or dull• Constant or intermittent• Diffuse or localized
• May be referred to shoulder
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Ectopic Pregnancy
• Physical Exam• S/S of hypovolemic shock• Positive tilt test• Tender lower abdomen • Palpable mass may be present
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Ectopic Pregnancy
• Management• High concentration oxygen• IV or IV’s with LR• MAST• Immediate transport
Abdominal pain or unexplained hypovolemia + woman of child-bearing age =
Ectopic pregnancy Until proven otherwise!
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Abortion
• Termination of pregnancy before fetal viability (20th week)
• Induced• Therapeutic• Criminal• Elective
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Abortion
• Spontaneous• 20 -25% of pregnancies terminate
spontaneously • Usually due to embryo abnormalities• May also result from infection, unfavorable
intrauterine environment, cervical incompetence
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Abortion
• Spontaneous• Threatened• Inevitable• Complete• Incomplete
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Abortion
• Threatened• Vaginal bleeding, mild or absent
contractions, closed cervix• 20% of women bleed in early pregnancy
• 50% go on to abort
• Any bleeding in early pregnancy is dangerous and abnormal
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Abortion
• Inevitable• Vaginal bleeding• Moderately severe contractions• Possible amniotic sac rupture• Cervix effacement and dilation• Changes are irreversible
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Abortion
• Completed• Products of conception expelled
• fetus
• placenta
• decidual lining
• Signs, symptoms• Profuse vaginal bleeding
• Passage of tissue, clots
• Continuing mild contractions
• Possible hypotension
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Abortion
• Incomplete• Products of conception retained• Signs, symptoms
• Profuse bleeding
• Passage of tissue/clots
• Severe contractions
• Hypotension, shock
• Sepsis
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Abortion
• Missed• Fetus dies in utero before 20th week• Retained at least 2 months afterwards• Signs/Symptoms
• Continued amenorrhea • History of bleeding without cramping• Decrease in uterine size
• Resorption of fluid• Calcification of products of conception
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Abortion
• History• Confirmed or suspected pregnancy
• Abdominal pain, cramping
• Bleeding, passage of tissue
• Physical Exam• Orthostatic vital signs (tilt test)
• Examine for amount of vaginal bleeding, presence of tissue
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Abortion
• Management• High concentration oxygen• IV or IV’s with LR• MAST if indicated• Do NOT pack vagina• Save any tissue passed• Transport
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Medical Complications
• Diabetes• Stable may become unstable• Gestational• Can not use oral medications
• Neuromuscular• May be aggravated by pregnancy
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Medical Complications
• Hypertension• More susceptible to complications
• CVA
• Cardiac Failure
• Renal Failure
• May be complicated by preeclampsia or eclampsia
• Cardiac Disorders• Additional stress placed on heart
• CO increases 30% by week 34
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Pregnancy-Induced Hypertension
• Two Phases:• Pre-eclampsia• Eclampsia
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Pre-Eclampsia
• In about 7% of pregnancies
• Between 20th week gestation, first week postpartum
• Hypertension, albuminuria, edema
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Pre-Eclampsia
• Risk Factors• First pregnancies
• Multiple gestations
• excessive amniotic fluid
• Diabetes mellitus
• Renal disease
• Pre-existing hypertension
• Family history of pre-eclampsia
• Poor nutrition
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Pre-Eclampsia
• Signs/Symptoms• Elevated BP
• >140/90 or >30mmHg above patient normal
• Edema of face/hands• Especially in morning
• Rapid weight gain• >3lb/wk - 2nd trimester
• >1lb/wk - 3rd trimester
• Decreased urine output
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Pre-Eclampsia
• Signs/Symptoms (Cont.)• Severe headache • Blurred vision • Irritability• Nausea, vomiting• Epigastric pain• Pulmonary edema
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Eclampsia
Pre-eclampsia + Seizures, Coma
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Pregnancy-Induced Hypertension
• Management• High concentration oxygen• IV tko• Left lateral recumbent position• Quiet environment• Reduce excessive light
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Pregnancy-Induced Hypertension
• Psychological support
• Avoid lights/sirens in pre-eclampsia
• Magnesium sulfate • 4gm bolus; 1gm/hr infusion• Monitor pulse, BP, respiration, patellar
reflex• Calcium will reverse toxicity
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Pregnancy-Induced Hypertension
• Assess every pregnant patient for:• Increased BP• Edema
• Take all reported seizures in pregnant females seriously
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Third Trimester Bleeding
• 50% due to normal changes in cervix
• 50% due to placental catastrophe
• Dangerous if amount greater than normal period
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Abruptio Placentae
• Premature placental separation from uterus
• 0.4 - 3.5% of pregnancies
• Risk Factors• Older patients• Hypertensives• Multigravidas• Trauma
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Abruptio Placentae
• Mild to moderate vaginal bleeding
• Continuous, knife-like abdominal pain
• Third trimester pain = Abruption until proven otherwise
• Rigid tender uterus
• S/S of hypovolemia• Out of proportion to visible
bleeding
• Alteration of contraction pattern
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Placenta Previa
• Placental implantation over cervical opening• 0.5% of pregnancies• Predisposing factors
• increasing age
• multiparity
• previous cesarean sections
• Can lead to • placental insufficiency
• fetal hypoxia
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Placenta Previa
• Painless, bright-red vaginal bleeding
• Soft, non-tender uterus• No contractions• S/S of hypovolemia
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Third Trimester Bleeding
• Management• 100% Oxygen• IV of LR x 2• Left lateral recumbent position• MAST, legs only
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Supine Hypotensive Syndrome• Uterus compresses inferior vena cava • Venous return to heart decreases• Decreased venous return leads to decreased
cardiac output• BP decreases• Consider volume depletion• Management
• Place patient on left side to restore venous return• Transport all non-laboring patients in late pregnancy
on left side
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Ruptured Membranes
• Vaginal leakage of clear, colorless fluid• 84% labor spontaneously in 24 hours, BUT• 50% become infected in 12 hours• Increased time = Increased infection risk• Patient MUST come to hospital
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Fever/Dysuria
• Major medical emergency
• Suggests urinary tract or amniotic fluid infection
• Sepsis or early labor may result
• Patient MUST come to hospital
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Uterine Rupture
• Common causes:• Prolonged labor against obstruction• Large fetus• Old C-section• Multiple pregnancies
• Signs/Symptoms• Sudden, intense, tearing abdominal pain• S/S of hypovolemic shock• Loss of continuity of uterine mass• Possible vaginal bleeding
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Uterine Rupture
• 50 - 75% fetal mortality
• Management• 100% Oxygen• IV of LR x 2• Left lateral recumbent position• MAST, legs only• Rapid transport
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Uterine Rupture
• History of previous C-section• Transport immediately unless baby is
crowning• Determine reason for C-section
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Trauma in Pregnancy• Minor Trauma
• Common in the Obstetric Patient• Syncopal episodes• Diminished coordination• Loosening of the joints
• Major Trauma• Susceptible to a life threatening episode
• increased vascularity• may deteriorate suddenly
• Leading cause of maternal death in pregnancy• MVC’s = 50% of perinatal mortality
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Trauma in Pregnancy
• Trauma can lead to • Premature separation of the placenta• Premature labor• Abortion• Rupture of the uterus• Fetal death
• Death of mother
• Separation of the placenta
• Maternal shock
• Uterine rupture
• Fetal head injury
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Trauma in Pregnancy
• Injured woman of child-bearing age, consider pregnancy
• Priorities EXACTLY same as in any other patient
• ABC’s first
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Trauma in Pregnancy
• Assessment• Vital signs mimic hypovolemia
• Pulse increases 10-15/minute• BP decreases
• Blood volume increases up to 45%• More blood loss can occur before S/S of
hypovolemia appear• In hypovolemia, blood is shunted from
placenta causing fetal distress
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Trauma in Pregnancy
• Assessment• Increased fluid volume needed to treat
hypovolemia• Penetrating abdominal trauma in second,
third trimester frequently involves uterus• Greatest danger from uterine injury is
hypovolemia
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Trauma in Pregnancy
• Assessment• Second, third trimester blunt abdominal
trauma may cause: • Uterine rupture
• Placental abruption
• Premature labor
• Hemorrhage from uterine vessels
• “Loose” joints mimic orthopedic injury• Particularly pelvic fracture
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Trauma in Pregnancy
• Management• Treat shock early, aggressively
• Fetus may be distressed when mother is not
• S/S of shock appear later
• More volume needed to correct hypovolemia
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Trauma in Pregnancy
• Management• Oxygenate aggressively• Consider assisting ventilation early
• Oxygen demand increases 10-20% in last trimester
• High diaphragm causes decreased compliance, tidal volume
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Trauma in Pregnancy
• Management• MAST can be used in late-term pregnancy
• Inflate legs only
• Using abdominal compartment reduces blood flow to fetus
• After first trimester never transport patient flat on back• Transport on left side
• Prop up right side of spine board with blanket, pillows
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Trauma in Pregnancy
• Most common cause of fetal death from trauma is maternal death
• Keeping mom alive keeps baby alive
• What’s good for mom is good for baby
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Braxton-Hicks Contractions
• Usually occurs in the third trimester
• Benign phenomenon that simulates labor
• Contractions are generally painless
• Walking may help
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Preterm labor
• Labor that begins prior to 38 weeks gestation
• Labor results in progressive dilation and effacement of cervix
• Causes• Multiple gestations
• Intrauterine infections
• Premature rupture of the membranes
• Uterine or cervical anatomical abnormalities
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Preterm labor
• Management• Consideration of tocolysis
• Rest
• Fluids
• Sedation
• Transport for evaluation
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Obstetric Patient Assessment
• Recognition of pregnancy• Breast tenderness• Urinary frequency• Amenorrhea• Nausea/Vomiting
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Obstetric Patient Assessment
• Obstetric History• Gravidity and Parity
• Gravidity = Number of pregnancies• Parity = Number of live births
• Last normal menstrual period• Estimated delivery date (-3/+7)• Previous Ob-Gyn complications• Prenatal care (by whom)• Previous Cesarean sections
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Obstetric Patient Assessment
• Obstetric Physical Exam• Evaluation of Uterine Size
• 12 to 16 weeks: above symphysis pubis
• 20 weeks: at umbilicus
• For each week beyond 20 weeks: 1 cm above umbilicus
• At term: near xiphoid process
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Obstetric Patient Assessment
• Obstetric Physical Exam• Presence of fetal movements
• ~20th week
• Presence of fetal heat tones• ~20th week
• Normal: 120 to 160/minute
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Obstetric Patient Assessment
• Presence of Pain• Abdominal pain in last trimester suggests
abruption until proven otherwise• Appendicitis may present with RUQ pain
• Presence of vaginal bleeding• Always dangerous in first trimester• Dangerous in late pregnancy if greater than
normal period
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Obstetric Patient Assessment
• General health• Diabetes may become unstable
• Hypoglycemic episodes in early pregnancy
• Hyperglycemia as pregnancy progresses
• Hypertension complicated by PIH• Cardiovascular disease may worsen
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Obstetric Patient Assessment
• Do tilt test if blood loss is suspected
• Do NOT tilt patient with obvious shock
Do NOT performvaginalexams!
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Obstetric Patient Assessment
• Warning signs• Vaginal bleeding
• Swelling of face, hands
• Dimmed, blurred vision
• Abdominal pain
• Persistent vomiting
• Chills, fever
• Dysuria
• Fluid escape from vagina
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QUESTIONSQUESTIONS
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